MEDICARE: ACADEMIC HEMATOLOGY ONCOLOGY, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QX0200X	Oncology Clinic/Center

General Provider Information

NPI Number	:	1902329501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACADEMIC HEMATOLOGY ONCOLOGY, PC

Provider Business Mailing Address
First Line	:	30700 TELEGRAPH RD STE 1536
Second Line	:
City	:	BINGHAM FARMS
State	:	MI
Zip	:	48025-4590
Country	:	US
Telephone Number	:	248-215-0048
Fax Number	:

Provider Business Practice Location Address
First Line	:	23850 VAN BORN RD
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48125-2325
Country	:	US
Telephone Number	:	313-647-3245
Fax Number	:	313-577-0977

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	AYAD AL-KATIB
Credential	:	M.D.
Telephone Number	:	313-647-3245

Provider Enumeration Date	:	07/25/2017
Last Update Date	:	07/25/2017

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